When Allergy & Rheumatology Collide

Since the last blog I've decided AJ will stop seeing urology - at least for the time being.  There were some abnormalities (duplex kidney, hydronephrosis, bladder wall thickening and enuresis) but no glaring diagnosis or fix.

AJ saw Rheumatology first on Sept 20 and again today Nov 27.  Still unexplained symptoms and "next step" for Rheumatology to review history and labs again with Dermatology and Allergy.  Allergy has said it's a Rheumatology issue and Rheumatology has said it's an Allergy issue.  Both agree he has urticaria and demographism but no explanation for the joint pain, swelling, hot spots and bruising.  He had negative allergy tests and negative autoimmune tests.  We are told to maximize antihistamine therapy and ibuprofen (Zyrtec 1 mg/mL 1 tsp twice daily, Zantac 15 mg/mL 1 tsp twice daily and Iburpropen 10 mL every 6 hours as needed).  Follow up is with Rheumatology in 2 months and labs will be re-done.

SYMPTOM SUMMARY:
-Rashes
-Swelling (internal / external)
-Stomach pain / loss of appetite / constipation
-Joint pain / hard knots
-Bruising / hot spots

LAB SUMMARY:
-negative Allergies
-negative ANA labs
-negative Angioedema
-negative Cystic Fibrosis
-negative Tethered Cord
-normal VCUG
-normal Spinal MRI
-normal Abdominal X-ray

My "mommy knows" diagnosis:
He has an autoimmune issue that causes the symptoms.  When he is sick with an infection his autoimmune issue which is already mis-firing goes into an all out battle and that's when the severe symptoms occur.

I will continue to track symptoms and take pictures of rashes, swelling and bruising.  If symptoms get any worse I am prepared to get another Rheumatology opinion.  I'm hoping the labs in 2 months are more helpful.

Next Procedure - VCUG

The results of my son's (AJ) spinal MRI were normal - meaning no tethered cord.  The urologist still has concerns (considering reflux or a blockage) and has ordered a VCUG.  Unfortunately, the blood work he had done (CMP, TSH, ANA, CBC, C1 Estrase, C4, Serum IGE and Sed Rate) wasn't gathered correctly so that will have to be redone. In addition, the Allergist / Immunologist that we were seeing came to the conclusion that his symptoms (facial & foot swelling, rash - flat / non-itchy and joint pain / swelling) was no longer an issue he could help with and referred us to a Rheumatologist and Dermatologist.  At this point, doctors don't seem to think AJ's urinary concerns (enuresis, duplex kidney, hydronephrosis and bladder wall thickening) and his body rash, facial & foot swelling / joint pain are related.

Courtesy of  http://www.chp.edu/CHP/Voiding+Cystourethrogram, here is some information about a Pediatric VCUG:

Fast Facts About VCUG

• The VCUG is a video X-ray of the bladder and urinary tract.
• Your child may eat and drink as usual before the test.
• Your child will be awake at all times.
• The test takes about 30 minutes.
• He or she can resume normal activities afterward.

What Is A Voiding Cystourethrogram (VCUG)?

A voiding cystourethrogram (sis-toe-you-ree-throw-gram), or VCUG, is a video X-ray of the bladder and urinary tract at work. The bladder stores urine made by the kidneys until it is time for your child to go to the bathroom.  

• To begin the test, your child’s bladder will be filled with a special liquid that will be visible on an X-ray.  
• A VCUG shows doctors how well the bladder and urinary tract are working. This includes the tubes (ureters) that connect the kidneys to the bladder and the urethra, which is the tube connecting the bladder to the outside of the body.
• A VCUG gives doctors detailed information about your child’s bladder and urinary tract that they cannot learn from a physical examination or other kinds of tests. 

Home Preparation

• No special preparation is needed.  
• Eat and drink as usual.

The Test 

A VCUG is (usually) done at (a) Children’s Hospital. In the room will be a pediatric radiology doctor, an X-ray technologist and, sometimes, a nurse. You will see an X-ray machine, a long table and a television screen. You might explain to your child that the X-ray is a large camera for taking pictures that will be shown on the screen.

• Your child is awake during this test.
• The test takes about 30 minutes. 
• Your child will be asked to remove his or her clothing, put on a hospital gown and lie on the table on top of a soft white pad. What happens next depends on whether your child is a girl or boy. 

For Boys

A boy will be asked to lie on the table. The doctor or X-ray technologist will wash the tip of his penis around the opening where the urine comes out, using a cotton swab and liquid soap. This may feel cold.

• The X-ray technologist will then slide a tiny, soft tube, called a catheter, into the opening of the penis. This can be a bit unpleasant, and he may need comforting.
• The X-ray technologist will dim the lights in the room so that the television screen can be seen.
• The doctor will then begin to take X-rays, moving the X-ray machine over your child, but not touching him. The X-ray machine will make a clicking noise as it takes pictures.
• X-rays will be taken as the liquid flows through the catheter and into the child’s bladder. When the bladder is full, he will be asked to urinate into a special bottle. This will make the catheter fall out.
• More X-rays will be taken while he is emptying his bladder.

For Girls

A girl will be asked to lie on the table holding her legs in a “frog position,” bending her knees and putting the bottoms of her feet together. Using a cotton swab and a liquid soap, the doctor or X-ray technologist will wash between her legs to clean the skin. This may feel cold.  

• The X-ray technologist will then slide a tiny, soft tube, called a catheter, into the opening where the urine leaves her body. This can be a bit unpleasant, and she may need comforting.  
• The X-ray technologist will dim the lights in the room so that the television screen can be seen.  
• The doctor will then begin to take X-rays, moving the X-ray machine over your child, but not touching her. The X-ray machine will make a clicking noise as it takes pictures.
• X-rays will be taken as the liquid flows through the catheter and into your child’s bladder. When the bladder is full, she will be asked to urinate on a pad or in a bedpan. This will make the catheter fall out.
• The X-ray technologist will ask her to push out all of the liquid while more X-rays are taken. She may feel awkward, but it is an important part of the test.

After the Test

When the doctor and X-ray technologist have taken all the X-rays they need, they will check to make sure the pictures are clear, which takes only a few minutes. Before leaving, you will be given contact information for questions and you will be told about follow-up care.

• After a VCUG, your child might feel a little sore the next few times he or she has to urinate. Drinking more liquids may help relieve the soreness more quickly.
• A report of your child’s VCUG will be sent to the doctor who prescribed it, usually within 48 hours. If the results are urgent, the referring doctor will be contacted immediately.  
• Please contact the doctor who prescribed the VCUG for the results.

Big Picture

Tomorrow we get the results of my son's spinal MRI and repeat Ultrasound (autoimmune lab results next week).  I find myself trying to look up specific things and then coming back to the big picture.  I want to ask questions.  I know all the symptoms, tests, medications and specialists we've seen.  I want to make sure that the big picture is acknowledged and taken into consideration for the diagnosis. The big picture is:

SYMPTOMS:
-Swelling (mostly facial, some foot)
-Hives (non-itchy) / Lumps (belly button, foot) / Bruising (buttocks)
-Incontinence / Frequent constipation / diarrhea
-Recurrent Infections (mostly throat) / Cough / Asthma
-Stomach / Back pain

KNOWNS:
-Duplex Kidney = positive
-Angioedema  = suspected
-Tethered Cord = suspected
-Cystic Fibrosis = negative
-Allergies (environmental / food) = negative

MEDICATIONS:
-Flonase (daily)
-Flovent (daily)
-Zyrtec (daily)
-Xopenex (as needed)

DOCTORS:
-Pediatrician (currently)
-Urology (currently)
-Allergy, Asthma, Immunology (currently)
-ENT (as needed)
-Pulmonology (previously)
-Infectious Disease (previously)

QUESTIONS:
-Could Angioedema be the reason for swollen kidney with fluid, bladder wall thickening and incontinence?
-Could a neurological issue be the reason for swelling and incontinence?
-What other possibilities should be considered?
-Should the autoimmune labs be considered?

TIPS:
I believe parents to be the child's biggest advocate and an integral part of the correct diagnosis. Big pictures are important and should be brought up to every doctor you see.  Make copies of lab results or summaries from various doctors and share those in your appointments. Listen to your "gut"...don't be afraid to ask questions.

MRI

Magnetic resonance imaging (MRI) is a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within your body.

Most MRI machines are large, tube-shaped magnets. When you lie inside an MRI machine, the magnetic field temporarily aligns the water molecules in your body. Radio waves cause these aligned particles to produce very faint signals, which are used to create cross-sectional MRI images — like slices in a loaf of bread.

The MRI machine can also be used to produce 3-D images that may be viewed from many different angles. (www.mayoclinic.com)

Our urologist ordered a full spinal MRI for my son mostly prompted by the suspicion of a Tethered Cord spine (see my previous post "Duplex Kidney" for more information on Tethered Cord).  I always use the pediatric or children's imaging centers versus the general imaging centers.  The children's imaging centers specialize in kids so they understand the fears, possible pain and parent concern and can usually do more to accommodate families.  Especially if sedation is involved I choose the children's imaging center.  

My son was given oral sedation (Vistaril and then Chloral Hydrate) in a private patient room with a bed, chairs and a TV / DVD player.  He picked a movie he wanted to watch and fell asleep about 30 minutes after sedation (some kids don't fall asleep but become very sleepy and relaxed).  My husband and I got to go in to the MRI room with him.  It was a VERY long process.  Even with sedation, he moved a few times so some parts had to be re-imaged.  The nurse in the room with us figured out he was too hot and was moving in an attempt to get out from under the sheets and blankets.  Once those were removed he was still for the remainder of the imaging. His eyes open a few times but he was so groggy the nurse would just tell him to close his eyes and go back to sleep and he would.  Sedation is not required for an MRI but I highly recommend it even with the possible risks.  I think to be strapped down to a table and rolled in to a tube with extremely loud noises is very scary even for adults.  Not to mention the fact that you have to remain completely still or the images get blurred and are useless or have to be repeated.  The amount of time the MRI takes depends on the images ordered.  My son's MRI took about 1.5 hours but some are as short as 10 minutes.  

After the MRI, my son was taken back to the private patient room for recovery.  We also had some blood work that another doctor had ordered that I took with me to have done while we were there (I wanted to take advantage of the sedation so he wouldn't feel the worry and pain of a blood draw).  After the draw, we waited for him to wake up and eat / drink a little before he could be released.  The nurse checked vitals and waited to make sure the food / drink didn't make him nauseous.  About 30 minutes later we were released.  My son was very wobbly and a little cranky the rest of the evening.  That was to be expected due to the sedation.  If your child has sedation - do not let him/her walk alone.  Either carry them or hold their hand when walking because they definitely have weakness and loss of balance several hours afterward.  I made a bed for him on the floor next to my bed that evening so he wouldn't roll out of his bed or try to get up and fall and hurt myself while still under the effect of the sedation.  This morning he woke up fine and totally back to normal.

We get the results of our MRI in 3 days and the results of our blood work next week.

TIPS:

1. Use a pediatric imaging center when possible.

2. Consider sedation.

3. If sedation is planned ask your child's other doctors if any labs are needed so the blood draw can be done  while sedated - less scary / painful.

Lab Panels / Definitions

COMP METABOLIC PANEL


The Comprehensive Metabolic Panel (CMP) is a frequently ordered panel of tests that gives your doctor important information about the current status of your kidneys, liver, and electrolyte and acid/base balance as well as of your blood sugar and blood proteins. Abnormal results, and especially combinations of abnormal results, can indicate a problem that needs to be addressed. The CMP is typically a group of 14 specific tests that have been approved, named, and assigned a CPT code (a Current Procedural Terminology number) as a panel by Medicare, although labs may adjust the number of tests up or down. Since the majority of insurance companies also use these names and CPT codes in their claim processing, this grouping of tests has become standardized throughout the United States.


The CMP includes:

• Glucose
• Calcium

Both increased and decreased levels can be significant.

Proteins

• Albumin
• Total Protein

Albumin, a small protein produced in the liver, is the major protein in serum. Total protein measures albumin as well as all other proteins in serum. Both increases and decreases in these test results can be significant.

Electrolytes

• Sodium
• Potassium 
• CO2 (carbon dioxide, bicarbonate)
• Chloride

The concentrations of sodium and potassium are tightly regulated by the body as is the balance between the four molecules. Electrolyte (and acid-base) imbalances can be present with a wide variety of acute and chronic illnesses. Chloride and CO2 tests are rarely ordered by themselves.

Kidney Tests

• BUN (blood urea nitrogen)
• Creatinine

BUN and creatinine are waste products filtered out of the blood by the kidneys. Increased concentrations in the blood may indicate a temporary or chronic decrease in kidney function. When not ordered as part of the CMP, they are still usually ordered together.

Liver Tests

• ALP (alkaline phosphatase)
• ALT (alanine amino transferase, also called SGPT)
• AST (aspartate amino transferase, also called SGOT)
• Bilirubin

ALP, ALT, and AST are enzymes found in the liver and other tissues. Bilirubin is a waste product produced by the liver as it breaks down and recycles aged red blood cells. All can be found in elevated concentrations in the blood with liver disease or dysfunction.

How is the sample collected for testing?
The CMP uses a tube of blood collected by inserting a needle into a vein in your arm. Ask your doctor whether you should be fasting for 10 to 12 hours prior to the blood draw. Depending on the reason for ordering the CMP, it may be drawn after fasting or on a random basis.

How is it used?
The CMP is used as a broad screening tool to evaluate organ function and check for conditions such as diabetes, liver disease, and kidney disease. The CMP may also be ordered to monitor known conditions, such as hypertension, and to monitor patients taking specific medications for any kidney- or liver-related side effects. If your doctor is interested in following two or more individual CMP components, he may order the entire CMP because it offers more information.

http://labtestsonline.org/understanding/analytes/cmp/tab/glance

SED RATE

A sedimentation rate is common blood test that is used to detect and monitor inflammation in the body. The sedimentation rate is also called the erythrocyte sedimentation rate because it is a measure of the red blood cells (erythrocytes) sedimenting in a tube over a given period of time. Sedimentation rate is often abbreviated as sed rate or ESR. http://www.medicinenet.com/sedimentation_rate/article.htm

TSH (THYROID STIMULATING HORMONE)

The TSH test is often the test of choice for evaluating thyroid function and/or symptoms of hyperthyroidism orhypothyroidism. It is frequently ordered along with or preceding a T4 test. Other thyroid tests that may be ordered include aT3 test and thyroid antibodies (if autoimmune-related thyroid disease is suspected).

TSH testing is used to:

• Diagnose a thyroid disorder in a person with symptoms
• Screen newborns for an underactive thyroid
• Monitor thyroid replacement therapy in people with hypothyroidism
• Diagnose and monitor female infertility problems
• Help evaluate the function of the pituitary gland (occasionally)
• Screen adults for thyroid disorders, although expert opinions vary on who can benefit from screening and at what age to begin

When is it ordered?

The doctor may order a TSH test when someone has symptoms of hyperthyroidism or hypothyroidism and/or when a person has an enlarged thyroid gland.

Signs and symptoms of hyperthyroidism may include:

• Increased heart rate
• Anxiety
• Weight loss
• Difficulty sleeping
• Tremors in the hands
• Weakness
• Diarrhea (sometimes)
• Light sensitivity, visual disturbances
• The eyes may be affected: puffiness around the eyes, dryness, irritation, and, in some cases, bulging of the eyes.

Symptoms of hypothyroidism may include:

• Weight gain
• Dry skin
• Constipation
• Cold intolerance
• Puffy skin
• Hair loss
• Fatigue
• Menstrual irregularity in women

It may be ordered at regular intervals to monitor the effectiveness of treatment when someone is being treated for a knownthyroid disorder.

TSH screening is routinely performed in the United States on newborns as part of each state's newborn screening program. The American Thyroid Association recommends that adults older than age 35 be screened for thyroid disease with a TSH test every five years, although other organizations, such as the U.S. Preventive Services Task Force, challenge this recommendation. Several organizations recommend instead screening women over 50 or those at high risk for thyroid disorders, such as pregnant and postpartum women.

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What does the test result mean?

A high TSH result often means an underactive thyroid gland that is not responding adequately to the stimulation of TSH due to some type of acute or chronic thyroid dysfunction. Rarely, a high TSH result can indicate a problem with the pituitary gland, such as a tumor producing unregulated levels of TSH. A high TSH value can also occur when someone with a known thyroid disorder or who has had their thyroid gland removed is receiving too little thyroid hormone medication.

A low TSH result can indicate an overactive thyroid gland (hyperthyroidism) or excessive amounts of thyroid hormone medication in those who are being treated for an underactive (or removed) thyroid gland. Rarely, a low TSH result may indicate damage to the pituitary gland that prevents it from producing adequate amounts of TSH.

Whether high or low, an abnormal TSH indicates an excess or deficiency in the amount of thyroid hormone available to the body, but it does not indicate the reason why. An abnormal TSH test result is usually followed by additional testing to investigate the cause of the increase or decrease.

The following table summarizes test results and their potential meaning.

TSH	T4	T3	INTERPRETATION
High	Normal	Normal	Mild (subclinical) hypothyroidism
High	Low	Low or normal	Hypothyroidism
Low	Normal	Normal	Mild (subclinical) hyperthyroidism
Low	High or normal	High or normal	Hyperthyroidism
Low	Low or normal	Low or normal	Non-thyroidal illness; rare pituitary (secondary) hypothyroidism

C1 ESTERASE

• Complement

• Complement component 3 (C3)

• Complement component 4 (C4)

• CH50

• CH100

How the Test is Performed
How to Prepare for the Test
How the Test Will Feel
Why the Test is Performed
Normal Results
What Abnormal Results Mean
Risks

• Excessive bleeding

• Fainting or feeling light-headed

• Hematoma (blood accumulating under the skin)

• Infection (a slight risk any time the skin is broken)

Alternative Names


C1 esterase inhibitor (C1-INH) is a protein found in the fluid part of your blood that controls C1, the first component of the complement system. The complement system is a group of proteins that move freely through your bloodstream. The proteins work with your immune system and play a role in the development of inflammation. There are nine major complement proteins. They are labeled C1 through C9.

Complement factors are very important in testing for autoimmune diseases, especially systemic lupus erythematosus. C1-INH is an important marker for hereditary angioedema, and it also plays a role in other diseases.

This article discusses the test that is done to measures the amount of C1-INH in your blood.

No special preparation is needed.

When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

Your doctor may order this test if you have signs of hereditary angioedema. Hereditary angioedema is caused by low levels of C1-INH.

C1 esterase inhibitor: 16 to 33 milligrams per deciliter (mg/dL).

Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

The examples above show the common measurements for results for these tests. Some laboratories use different measurements or may test different specimens.

Abnormal results may be due to certain types of angioedema.

Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining blood from some people may be more difficult than from others.

Other risks associated with having blood drawn are slight but may include:

C1 inhibiting factor; C1-INH

C4 LEVEL

Complement component 4 is a blood test that measures the activity of a certain protein that is part of the complement system. The complement system is a group of proteins that move freely through your bloodstream. The proteins work with your immune system and play a role in the development of inflammation.

There are nine major complement proteins. They are labeled C1 through C9. This test measures C4.

See also:

• Complement
• Complement component 3 (C3)
• CH50
• CH100

How the Test is Performed

Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein swell with blood.

Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight vial or tube attached to the needle. The elastic band is removed from your arm.

Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding.

In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. A bandage may be placed over the area if there is any bleeding.

The sample is then sent to the laboratory where the amount of C4 is measured.

How to Prepare for the Test

No special preparation is needed.

How the Test Will Feel

When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

If your child is to have this test performed it may be helpful to explain how the test will feel, and even practice or demonstrate on a doll. The more familiar your child is with what will happen to them, and the purpose for the procedure, the less anxiety he or she will feel.

Why the Test is Performed

C3 and C4 are the most commonly measured complement components. Complement activity may be measured to determine how severe a disease is or if treatment is working.

A complement test may be used to monitor patients with an autoimmune disorder. For example, patients with active lupus erythematosus may have lower-than-normal levels of the complement proteins C3 and C4.

Complement activity varies throughout the body. For example, in patients with rheumatoid arthritis, complement activity may be normal or higher-than-normal in the blood, but much lower-than-normal in the joint fluid.

Normal Results

• Males: 12 to 72 mg/dL
• Females: 13 to 75 mg/dL

Note: mg/dL = milligrams per deciliter

Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

The examples above show the common measurements for results for these tests. Some laboratories use different measurements or may test different specimens.

What Abnormal Results Mean

Increased complement activity may be seen in:

• Cancer
• Ulcerative colitis

Decreased complement activity may be seen in:

• Bacterial infections (especially Neisseria)
• Cirrhosis
• Glomerulonephritis
• Hepatitis
• Hereditary angioedema
• Kidney transplant rejection
• Lupus nephritis
• Malnutrition
• Systemic lupus erythematosus

Alternative Names

C4

Urticaria related to Angioedema

My son woke up with a large rash on the outside of his right thigh and across his lower back / buttocks.  Diagnosis was urticaria (hives) related to Angioedema.  Hives can occur when histamine and other inflammatory chemicals are released from white blood cells (mast cells) in the skin.  These white blood cells are the same ones involved in allergic reactions in the nose and eyes (hayfever).   Mast cells are a part of the immune system and can be found throughout the body. Inside the mast cell are tiny granules containing different chemicals that cause inflammation. Related to skin diseases, mast cells play an important role in hives and facial flushing caused by mastocytosis.  A cause for chronic urticaria is found in less than 5% of cases. Topical therapies for hives are available but generally ineffective. Allergic reactions are not known to cause chronic urticaria and allergy tests are usually not helpful.  Hives have various looks.  The ones my son has look similar to those in the image found online below.  He has been taking 1 tsp (5mL) Zyrtec daily for the past few weeks for the swelling and due to this recent hives breakout we are taking 2 tsp (10mL) daily (1 tsp in the morning, 1 tsp at night).  

There are other rashes that may look like hives but the fact that they remain stable and do not resolve within 24 hours is helpful in distinguishing them from hives. Such rashes may need to have a small specimen of skin removed and examined under the microscope (biopsy) to accurately determine the nature of the skin disease. 

TIP:  Take a picture of the rash to show the doctor.  If the appearance changes take multiple pictures.  It can help in diagnosis. 

Duplex Kidney

I took my son to the Urologist for daytime and night time wetting concerns only to find out he has Kidney Duplication or "Duplex Kidneys".  It looks on the ultrasound like a kidney within a kidney but in reality is just two tubes (ureters - tubes that carry urine from the kidneys to the bladder) instead of just one coming from the kidney.  His right kidney is perfect, his left kidney is the Duplex Kidney.  (See the right side of the image below).  A duplex collecting system can result in frequent urinary tract infections, backflow of urine into the kidney and sometimes kidney damage.

We had an ultrasound done today that detected this as well as bladder wall thickening and a little fluid in the kidney.  We are scheduled to have an MRI (magnetic resonance imaging - a non-invasive scan) probably next week.  The MRI is to determine if he has "tethered cord" which is a condition where the spinal cord becomes stretched and damaged due to tissue that doesn't belong there.  It can cause urination control issues. It can also cause nerve damage if not treated. (See image below.)  The doctor suspected this when she noticed a crooked crease at the top of his buttocks.  

The fluid in the kidney can be a result of reflux (VUR - vesicoureteral reflux - an abnormal flow of urine from the bladder into the ureters or kidneys) but because he hasn't had urinary tract or kidney infections the doctors aren't worried at this point.  If concern develops a VCUG (voiding cystourethrogram - an x-ray examination of the bladder and lower urinary tract that uses a special form of x-ray called fluoroscopy; a catheter is used to fill the bladder with a liquid contrast to see if it flows backwards into the kidneys confirming VUR)  would be ordered for further analysis and treatment.

The duplex kidney, thickened bladder wall and possible tethered cord can all contribute to daytime / night time wetting.  He can't help the "leaking" or accidents.  For now we are using a timer watch set for every 2 hours as a reminder to potty and Miralax to make sure stools can easily move out of the body.  If after the watch and Miralax he still has problems there is medication he can take to help relax the bladder wall.  We'll wait for the MRI results to decide "next steps".  Next steps can be do nothing or do surgery or something in between depending on severity.

TIPS:  If you're child can't stay dry try a "potty watch" (recommended reminder set for every 2 hours; www.pottymd.com makes a "potty watch" that looks like a regular watch so it's not embarrassing for an older child to wear) and daily dose (usually 1/4 - 1/2 cap) of Miralax.  Sometimes constipation is the cause of leaks and accidents.  If there are still concerns see a pediatric urologist.